A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?
Inform the client that the nurse will get reprimanded for not administering the medication
Document the client’s refusal on the medication administration record
Ask the client the reason for refusing the medication
Inform the client that refusal is not permitted and it is required that the client take the medication
The Correct Answer is C
Choice A reason: Informing the client about potential nurse reprimands is coercive and inappropriate, as it prioritizes the nurse’s interests over patient autonomy. This approach fails to explore the client’s reasons for refusal, which may involve side effects or mistrust, and does not support therapeutic communication or ethical care.
Choice B reason: Documenting refusal is necessary but not the first action. Exploring the reason for refusal allows the nurse to address concerns, potentially resolving issues like misunderstanding or side effects. Documentation follows after attempts to understand and educate, ensuring a therapeutic approach before recording the refusal.
Choice C reason: Asking the reason for refusal respects autonomy and initiates therapeutic communication. It identifies barriers like side effect fears or lack of understanding, enabling education or alternative solutions. This approach aligns with patient-centered care, addressing underlying issues to promote adherence while respecting the client’s rights.
Choice D reason: Stating that refusal is not permitted is coercive and violates autonomy. Clients have the right to refuse medication unless under involuntary treatment orders. This approach damages trust, escalates resistance, and contradicts ethical principles, making it an inappropriate initial response to medication refusal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Sitting upright with uncrossed limbs at eye level conveys openness and engagement. Uncrossed arms and legs signal non-defensiveness, while eye-level positioning fosters equality and trust. This posture aligns with therapeutic communication principles, promoting a safe, accepting environment for the client to express emotions freely.
Choice B reason: Leaning forward with arms on a table may appear intrusive or aggressive, potentially making the client feel uncomfortable. While engagement is intended, this posture can reduce personal space, disrupting the therapeutic environment and hindering the client’s sense of safety and acceptance during the conversation.
Choice C reason: Sitting upright with feet on the floor is neutral but less specific in conveying acceptance. Without mention of uncrossed arms or eye-level positioning, it may not fully signal openness. While not negative, it lacks the full therapeutic posture needed to maximize client comfort and trust.
Choice D reason: Turning to the side with folded arms suggests defensiveness or disengagement, which can make the client feel unaccepted or dismissed. This posture contradicts therapeutic communication principles, as it creates a barrier to open dialogue and may hinder the client’s willingness to share emotions.
Correct Answer is C
Explanation
Choice A reason: Defense mechanisms, like denial or projection, can strain relationships by avoiding honest communication or projecting blame, disrupting trust and emotional connection. While they may temporarily reduce anxiety, they hinder interpersonal dynamics, making this a negative outcome rather than a positive one in therapeutic interactions.
Choice B reason: Defense mechanisms can impair problem-solving by avoiding reality (e.g., denial) or displacing emotions, preventing rational analysis of issues. This leads to maladaptive coping, which does not address underlying problems, making it a negative consequence rather than a positive outcome of using defense mechanisms in mental health contexts.
Choice C reason: Defense mechanisms, such as repression or rationalization, temporarily reduce anxiety by shielding the individual from overwhelming emotions or stressors. By mitigating psychological distress, they provide short-term emotional relief, allowing the person to function under stress, making this a positive outcome when used adaptively in mental health management.
Choice D reason: Defense mechanisms can inhibit emotional growth by preventing individuals from confronting and processing emotions, leading to unresolved issues. Overreliance on mechanisms like avoidance stalls emotional development, hindering self-awareness and coping skills, making this a negative outcome rather than a positive benefit of defense mechanisms.
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